- Accelerating Evidence Reviews and Broadening Evidence Standards to Identify Effective, Promising, and Emerging Policy and Environmental Strategies for Childhood Obesity Prevention
PUBLICATIONS and TOOLS
- Let's Move! Cities and Towns Releases New Toolkit
- CDC Releases Food Environment Guide
- RWJF Center Legislative Update
- Calorie Labeling Doesn't Change Fast-Food Orders
- AAAAI: Asthma Tracks Childhood Obesity
- Why Cartoon Characters Make Kids' Food Taste Better
- Parents May Be an Essential Component of their Children's Weight Loss
- Could a Type of Ear Infection Help Make Kids Obese?
CHILDHOOD OBESITY NEWS
- Let's Move! Can it Make a Dent in the Childhood Obesity Problem?
- Type 2 Diabetes Surges in People Younger Than 20
- Vilsack: Schools to Receive More Fresh Produce
- Deconstructing 'The Very Hungry Caterpillar': Excellent Food Choices, Portion Control Needs Work
Accelerating Evidence Reviews and Broadening Evidence Standards to Identify Effective, Promising, and Emerging Policy and Environmental Strategies for Childhood Obesity Prevention
By Laura Brennan [NCCOR Member], Sarah Castro, Ross C. Brownson, Julie Claus, and C. Tracy Orleans [NCCOR Member]
The childhood obesity epidemic has stimulated the emergence of many policy and environmental strategies to increase healthy eating and active living, with relatively few research recommendations identifying the most effective and generalizable strategies. Yet, local, state, and national decision makers have an urgent need to take action, particularly with respect to lower-income and racial and ethnic populations at greatest risk. With the surge of promising and emerging policy and environmental strategies, this review provides a framework, criteria, and process modeled from existing expert classification systems to assess the strength of evidence for these strategies. Likewise, this review highlights evidence gaps and ways to increase the types and amount of evidence available to inform policy and environmental strategies. These priorities include documenting independent and interdependent effects, determining applicability to different populations and settings, assessing implementation fidelity and feasibility, identifying cumulative benefits and costs, ascertaining impacts on health equity, and tracking sustainability.
PUBLICATIONS and TOOLS
Let's Move! Cities and Towns Releases New Toolkit
Let's Move! Cities and Towns is part of first lady Michelle Obama's Let's Move! initiative. It serves to engage mayors and other local leaders to join the effort to combat childhood obesity. A new toolkit was recently released to help these local policymakers adopt long-term, sustainable, and holistic approaches toward solving the childhood obesity epidemic crisis.
CDC Releases Food Environment Guide
The Centers for Disease Control and Prevention (CDC) has released a new guide to help states and localities develop, adopt, implement, and evaluate a food procurement policy with a focus on improving the food environment through nutrition standards.
RWJF Center Legislative Update
Keep up with the various federal bills about childhood obesity and obesity prevention. This page will keep you up to date with what's happening and how legislation is moving.
Calorie Labeling Doesn't Change Fast-Food Orders
March 7, 2011, USA Today
By Sophie Terbush
Calorie labeling in fast-food restaurants has no effect on the food purchases of parents or teens in low-income neighborhoods, according to a new study published in the International Journal of Obesity.
The study, led by Brian Elbel, assistant professor of medicine and health policy at New York University School of Medicine, shows that although calorie labels do increase awareness of calories, they do not necessarily influence food choices or the number of calories consumed.
The study surveyed customers and collected their purchase receipts at four major fast-food chains (Wendy's, Burger King, McDonald's and Kentucky Fried Chicken) in July 2008, before New York City's implementation of a new calorie labeling regulation, and again at the same locations one month after labeling began.
Both sets of samples were taken from low-income areas of the city, including East Harlem, South Bronx and Central Brooklyn; a control group sample was taken from Newark, an area with similar demographics and an urban setting.
Elbel says he assessed low-income neighborhoods because they tend to be of more fragile health and at higher risk for obesity, and they tend to be surrounded by higher concentrations of fast-food restaurants without other, more healthful food options.
"You'd like to see the effects of labeling on these at-risk groups, but it also makes it harder to see an impact on these groups because they're also choosing based on availability and price of food," not necessarily nutritional value, he says.
The 349 participants were children and adolescents ages 17 and under who visited the restaurants with their parents (69%) or alone (31%). About three-fourths of participants were from New York City, and 90 percent were from racial or ethnic minority groups. Adolescents who visited with parents tended to be younger and were not surveyed; instead, the parents completed the interviews.
The study shows that just over half of adolescents and adults noticed the calorie counts after labeling began in New York, but only 9 percent of adolescents and 16 percent of adults who saw the information said it mattered to them.
"Both populations are seeing it, but it's not translating into a change," Elbel says.
People purchased the same amount of calories before labeling began and after, the study shows; for adolescents, it was about 725 calories, and for adults, about 600 calories. Elbel says adolescents who were alone tended to buy more food than parents bought for their children.
In the choice of food for teens, habit, access, price and location matter some, but "taste is the most important factor," Elbel says. He also looked at how parents worked with their children to make fast-food choices.
In deciding what the children would eat, 57 percent of parents chose for their children, 31 percent let the child choose, and 6 percent said they chose together. Elbel says parents who chose for their children did not choose fewer calories than when the children were allowed to choose.
A national calorie-posting mandate also was part of the Patient Protection and Affordable Care Act of 2010. The U.S. Food and Drug Administration [had to] issue proposed regulations by March 23 for national calorie labeling.
That include[s] restaurants with 20 or more locations posting calorie counts on menu boards and in retail stores and having nutrient information available in writing upon request. Vending-machine operators with 20 or more machines also would be required to post caloric content for certain items.
For now, Elbel says that while many health researchers, policymakers and restaurant-chain owners are backing the national legislation, there is much more that can be done. "What we're starting to see is that (labeling) won't be enough to influence obesity by itself in a large-scale way," he says. "One of the best things for restaurant owners to do is to reformulate their menus."
Elbel's findings in the study are similar to those in a study he published in the October 2009 issue of the Health Affairs conducted in the same area of New York City, comparing calorie consumption of customers based on receipts gathered outside fast-food restaurants.
He is also analyzing data for a study with the same methodology that he conducted in Philadelphia, before and after calorie labeling took effect there, using Baltimore as a comparison city.
This study will assess a larger sample, looking at higher- and lower-income areas, and may provide more information about the effects of calorie labeling on a more diverse population.
AAAAI: Asthma Tracks Childhood Obesity
March 21, 2011, Med Page Today
By Ed Susman
Overweight children who become overweight young adults appear to have an increased risk of developing asthma compared with children who don't carry extra pounds or whose weight normalizes as they grow, researchers reported.
In a study of more than 800 children and young adults, those who were overweight in elementary school and after high school were 2.4 times (P=0.017) more likely to have asthma compared with those who were normal weight from childhood through late teens.
"The effect was more pronounced among boys," said Minto Porter, MD, a fellow in allergy and immunology at Henry Ford Hospital in Detroit, during her poster presentation at the annual American Academy of Allergy, Asthma & Immunology meeting here.
In her study, male subjects were 3.3 times (P=0.048) more likely to have asthma if they were overweight as children and as young adults. Girls had a 1.9-fold increased risk of having asthma (P=0.09), Porter said.
The results were consistent regardless of the presence or absence of atopy, Porter told MedPage Today.
She did note that children who are overweight as 6- to 8-year-olds and whose weight then normalized by the time they finished high school did not appear to have a statistically significant risk of developing asthma (P=0.73).
Similarly, children of normal weight in elementary school who then become overweight as teenagers do not appear to increase their risk of asthma (P=0.85), Porter explained. "Males with a body mass index equal to or greater than the 85th percentile when they are 6 to 8 years of age show an increased rate of current asthma at ages 18 to 20," Porter said.
"We believe that predisposing obesity among the younger children may be needed to trigger asthma at a later age if those children do not subsequently lose weight," she added. For their retrospective study, Porter and her colleagues examined medical records of children in the Detroit area in an attempt to determine if rising rates of obesity and asthma are associated.
"Many people believe that obesity precedes asthma," Porter remarked. "However, it is possible that asthma may limit one's ability to partake in physical activity, resulting in obesity."
To try to tease out a possible causal relationship, the research team interrogated the Detroit-area birth cohort of children of pregnant women enrolled in a local health maintenance organization.
The 815 children in the study were born between April 1987 and August 1989. The mothers underwent a prenatal interview and then were contacted by telephone annually until the child's sixth birthday.
Between ages 6 and 8, the children visited clinics, were interviewed by clinicians, and had medical histories taken. Between ages 18 to 20, interviews were repeated along with the subjects' medical history; the other group also submitted to a blood draw.
About half the group -- 424 individuals -- completed both the early testing and the examination a decade later.
"The message in this study is relatively simple: Don't over-feed kids" said William Schoenwetter, MD, an allergy specialist at Brainerd Medical Center, Minneapolis. "If you don't over-feed children we are going to have less asthma." Schoenwetter told MedPage Today that the researchers were fortunate to have access to the study records and that many of the participants were available for the follow-up
Among the findings:
- Of the 424 individuals who completed the study, eight were considered underweight at the initial examination, 323 were normal weight, 62 were overweight, and 31 were obese.
- Sixteen (7.1%) of 226 individuals who were normal weight at the beginning of the study and normal weight at the end developed asthma.
- Five (6%) of the 84 individuals who were normal weight at baseline but overweight as adults developed asthma.
- Just one (5.6%) of 17 individuals who were overweight as children but normal weight as young adults developed asthma.
- Twelve (16.5%) of those who were overweight as a child and still overweight as a young adult developed asthma.
Porter concluded that before a conclusive link between overweight status and asthma can be determined additional studies are needed, especially studies that include gender data as well as information about weight.
Why Cartoon Characters Make Kids' Food Taste Better
March 8, 2011, Time "Healthland"
By Alice Park
A new study finds that when kids see familiar and favorite characters from cartoons or movies on food packaging, they tend to like that food more.
That may not seem like such a revelation, but consider that in this particular experiment, the researchers fed the children the exact same food, and just changed the exterior appearance of the packaging. Such alterations were enough to actually change the way the youngsters tasted the food.
Led by Matthew Lapierre, who is working on his dissertation at the University of Pennsylvania's Annenberg School of Communication, the scientists devised four different boxes of cereal for 80 children to test. After analyzing existing children's cereals and the licensed characters appearing on their packaging, Lapierre's group decided to decorate two of the boxes with images of penguins from the movie Happy Feet. The penguins were familiar enough to children without being part of established marketing campaigns to bias the participants' perceptions of the cereal. The two remaining boxes contained no characters, just an image of the cereal.
The other variable the group tested was the name of the cereal — one of the penguin-containing packages was called Healthy Bits, while the other was named Sugar Bits, and the same was done for the boxes without the characters. The cereal inside all boxes was the same, an organic product that not many children would recognize.
As expected, the children, aged 4 to 6, consistently rated the penguin-adorned boxes of cereal as better tasting than the ones without the characters. But what surprised the researchers was that the effect went beyond a mere preference for a familiar logo or character.
Previous research involving familiar cartoon characters and snacks such as gummy bears, graham crackers, and carrots found that kids prefer packaged food branded with familiar characters, whether or not the food tastes better to them. Other studies involving McDonald's products asked children to choose between food wrapped in McDonald's logos or food lacking a recognizable brand, and children repeatedly opted for the McDonald's foods. But in the current analysis, researchers looked beyond cartoon preferences, and found that the same cereal actually tasted better to children when a penguin appeared on the box. "What struck us was that when you just slapped a character on the box, it changed the way kids tasted the cereal," says Lapierre. "We were expecting an effect, but we just didn't think it would be that profound an effect."
It adds to the evidence that marketing campaigns tying beloved and familiar characters to food products actually do work, and if parents would let them, influence how children eat. Children tend to react more emotionally and intuitively to events and objects than adults do, explains Lapierre, and experts believe that may be why they are particularly susceptible to advertising that relies on characters. "When children see a character they like on a product, what comes to mind is how much they like that character, and it carries over into their product assessment," he says. "Their ability to stop and think gets overwhelmed. Children have a difficult time overriding and using cognition to override that [emotional] response."
In fact, researchers at the Sesame Workshop found that when children were asked to choose between chocolate and broccoli, 78 percent opted for the chocolate bar and 22 percent favored the healthy vegetable. But when an Elmo sticker was placed on the broccoli, and an unfamiliar character was placed on the chocolate, the broccoli fans swelled to 50 percent.
But that doesn't necessarily mean that the presence of favored cartoon characters leaves children completely blind to taste or other factors. In the second portion of the study, the scientists tested children's responses to the two different names for the cereal, and to their utter surprise, found that children preferred Healthy Bits to Sugar Bits.
Why? Lapierre and his team are still scratching their head over that one, but theorize that one of two factors may be at work: First, the youngsters may be anticipating the way healthy and sugary cereals should taste, and since the cereal in the boxes was only lightly sweetened, their expectation for a more overwhelming sugar sensation when they ate Sugar Bits likely left them disappointed with that version. On the other hand, they might have been expecting a drier, unsweetened cereal with Healthy Bits and were therefore pleasantly surprised by the slightly sweet taste and ranked the Healthy version higher than the Sugar. Alternatively, says Lapierre, the children may have already been educated enough about nutrition from their parents to know that sugar isn't good for them, and thus said they preferred the Healthy Bits, knowing that's what their parents might expect them to say.
Lapierre notes that the power of characters in influencing how children actually think food tastes could be an effective tool in guiding children toward healthier and more nutritious choices. If Elmo can make broccoli seem appealing, then imagine what a phalanx of familiar characters could do in the fruit and vegetable section of the grocery store.
Parents May Be an Essential Component of their Children's Weight Loss
March 28, 2011, Los Angeles Times
By Jeannine Stein
For kids trying to lose weight and get in shape, parent involvement may be essential. A study released in March in the journal Pediatrics found that a parent-driven diet program was best at helping kids shed pounds and gain other health benefits.
The study involved 165 overweight children ranging in age from about 6 to 10 years old. Each was randomly assigned to one of three interventions: a diet program taught to parents by dietitians that focused on goal setting, problem solving, and positive reinforcement from parents; an activity program for kids taught by physical education teachers, with parents taking part early on and encouraged to do more at home with their kids; and a combination of the two programs, with parents and children both participating.
Children in all three groups reduced their body mass index and waist circumference after two years. However, at that two-year point the diet program and the combination program had better results than the activity program.
The authors noted that this detail was important, since it may mean that childhood obesity treatments could just involve parents' supervision of their kids' diets.
The implication, they said, is that parents' input might be necessary to see results: "In addition," they wrote, "parents can participate in intervention programs that will benefit their child without their child being required to participate."
Could a Type of Ear Infection Help Make Kids Obese?
March 21, 2011, Bloomberg Businessweek Health Day
By Amanda Gardner
New research hints at a surprising culprit for excess weight gain in kids: a certain type of ear infection.
The new study finds that chronic middle-ear infections with fluid are linked to alterations in children's taste buds that change their sensitivity to certain foods. This, in turn, might cause kids to eat more of these foods and push them towards obesity, the Korean researchers speculate.
But to see if chronic middle-ear infection actually helps cause obesity will take "larger studies with more patients," said Dr. Jeffrey P. Simons, assistant professor of otolaryngology at Children's Hospital of Pittsburgh. "As an initial study it's very provocative," he noted.
"This doesn't necessarily mean that one causes the other," added Simons, who was not involved with the study. "There are a lot of risk factors for [this type of ear infection]," he said.
The findings are published in the March issue of Archives of Otolaryngology -- Head & Neck Surgery.
Chronic otitis media with effusion (OME) "is basically middle-ear fluid that is present in the absence of acute infection for three months or more," Simons explained. "It tends not to have the classic signs of acute inflammation like pain and bulging ear drum and fever, although there can be symptoms [such as] a clogged sensation in the ear or decreased hearing."
Researchers have already noted a possible link between childhood obesity and chronic OME. This team of investigators speculated that related changes in taste buds might connect the two. According to the study, chronic ear infection and inflammation might affect a particular nerve, the chorda tympani, that controls taste at the front of the tongue.
"The nerve that supplies taste to the front two-thirds of the tongue goes right through the middle ear where the fluid is sitting," Simons explained. "[The authors' theory is that] there may be some chronic underlying inflammation of that nerve that increases sensation or increases the taste threshold," he said.
The investigators, from Kyung Hee University in Seoul, South Korea, conducted taste tests and measured body mass index (BMI) in two groups of children: 42 with chronic OME who were having a tube inserted to drain the fluid from their ear and another 42 children without chronic OME.
Children suffering from ear infections tended to be heavier than their counterparts. They also had reduced taste in the front part of the tongue, in particular, leading to a raised threshold for sweet and salt tastes. There was also a reduced ability to detect sour and bitter, but this was much less pronounced.
A higher taste threshold could indicate that children with chronic OME need to eat more food to get the sweet and salty tastes they crave, explained the study authors. And according to Simons, that could mean taking in more calories, "resulting in a contribution to obesity."
If this, in fact, does turn out to be the case, "this may be another reason to treat chronic OME," Simons reasoned. On the other hand, the relationship may not be so simple. Carolyn Landis, associate professor of pediatrics at Rainbow Babies & Children's Hospital at University Hospitals in Cleveland, said the connection might be the other way around, with obesity helping to cause ear infections.
"It's kind of a chicken-and-egg thing," she said. As the study noted, obese people do have a thicker fat padding around their ear, which can predispose them to ear infections.
"It would be interesting to explore this further but from this one study, we can't say much definitively," Landis said.
Original Source: http://www.businessweek.com/lifestyle/content/healthday/651092.html
CHILDHOOD OBESITY NEWS
Let's Move! Can it Make a Dent in the Childhood Obesity Problem?
March 20, 2011, Los Angeles Times
By Jessica Pauline Ogilvie
Can childhood obesity be eliminated in a generation? Will we ever get our children away from video games and into the park? Is there anything to be done about neighborhoods with a plethora of fast-food outlets and a dearth of options for eating healthfully?
A year ago, first lady Michelle Obama launched the Let's Move! campaign from the front lawn of the White House. She outlined her plan to focus on four primary objectives: educating and empowering parents, providing more-healthful foods in schools, increasing access to healthful foods in underserved neighborhoods, and encouraging more physical activity.
Among the specifics, Obama set the goal of doubling participation in the Healthier US School Challenge, which recognizes schools in the National School Lunch Program that have worked to promote more-healthful school environments. She also announced her intention of working with food retailers to stock more-healthful fare, and challenged kids and adults to exercise five days a week.
Many childhood obesity and nutrition experts believe that the first lady's initiative is an important step in raising national awareness about childhood obesity, which in 2008 reached an all-time high of 17% among kids age 2 through 19, according to the federal Centers for Disease Control and Prevention.
"Let's Move! is first time food issues have had this kind of legitimacy at this high a government level," said Marion Nestle, nutrition professor at New York University and the author of the book "Food Politics." "Just doing that is an enormous, enormous contribution."
But in a culture where junk food abounds and outdoor play continues to lose ground to controllers and computers, some experts are skeptical as to how successful the public awareness program — which also works to allocate funding for government agencies involved in nutrition and health, such as the Department of Health and Human Services — can be.
We spoke to five specialists in the fields of nutrition and childhood obesity to get their take on each aspect of the Let's Move! campaign:
In addition to purchasing food for the family, parents and caregivers serve as role models for healthy behavior. For that reason, said Dr. William Roberts, the president of the American College of Sports Medicine, reaching adults with information about good health practices, and encouraging them to examine their own habits, is a key part of battling childhood obesity.
"The apple doesn't fall far from the tree," said Roberts, who has a private practice in Minnesota. "I can often see who will have trouble with obesity and who won't from looking at the parents; obese parents have obese kids, and active parents have active kids."
According to a report by a task force implemented by President Obama to oversee Let's Move!, the campaign has worked with a handful of government agencies to help parents make more informed decisions. The Food and Drug Administration has begun to explore the effects of putting nutrition labels on the front of food packaging, and how it can be effectively implemented. The Department of Agriculture will soon release a new food pyramid, condensing its dietary guidelines. And Michelle Obama herself has urged restaurants across the country to provide nutritional information about their dishes.
Obesity Research Center, getting parents to change their behavior is likely to be much more challenging than putting numbers on menus and packaging.
"We're talking about changing what people eat, their physical activity levels," he said. "This has been very, very difficult to do and quite frankly, we have more failure than success."
A program like Let's Move! can help, he said, but "at the end of the day, it's a cultural shift, the way smoking is now unacceptable, not wearing seatbelts is now unacceptable. It's an amazing challenge and it's going to be a lot for any one program to do alone."
Getting healthful foods in schools
In December, President Obama signed the Healthy, Hunger-Free Kids Act of 2010, which provides funding for federal school meals and child nutrition programs and is reauthorized every five years. Informed, in part, by the Let's Move! objectives, the bill requires national standards to be set for food sold at schools, including meals and vending machine snacks.
Margo Wootan, director of nutrition policy at the Center for Science in the Public Interest, worked on the bill, and said that it's passage was a victory for Let's Move! program.
Getting junk food out of schools is "something we've wanted to do for decades," she said.
To ensure compliance with the bill, one school per district nationwide will be audited every three years, said Wootan.
"The review that they do is so comprehensive and labor intensive [that] it's hard for them to do many more schools," she said, adding that she'd like to see the review process more streamlined.
Some experts, however, see the bill as falling short of what kids need.
"I think we need universal school meals," said Nestle, referring to lunches provided to all children regardless of income, "and anything short of that is an enormous compromise."
Areas that are dominated by fast-food restaurants and have a dearth of healthful options are another target of the Let's Move! campaign.
The program made a significant stride in January, when Wal-Mart agreed to join Let's Move! by stocking its shelves with more-healthful more-clearly labeled products. The collaboration, said Nestle, represents an important step towards getting buy-in from the food industry, which has often viewed junk food as more profitable than more nutritious fare.
"Anything Wal-Mart does is going to have an enormous effect on other food companies, because they are going to have to follow suit," she said.
Still, said Hill, the effort within the food industry is "not as coordinated as we might like it to be." And it remains to be seen whether more-healthful options will lead to more-healthful choices.
"The question is, are people just waiting for healthy food, and once you bring it in they will eat it?" he said. "I suspect that's not the case. Getting people to make these healthy choices and sustain them over time is very much a challenge."
Increasing physical activity
Without an increase in physical activity, overweight kids are likely to remain that way. To that end, Let's Move! has teamed up with national sports organizations, including the National Football League and Major League Baseball, to develop public service announcements to motivate kids who may see professional athletes as role models.
But many believe that increasing physical activity represents the biggest challenge facing the program. "I think it's going to be easier to solve the food problem then the physical activity problem," said Hill.
Roberts suggests that schools need to support gym and recess and that city planners should keep in mind the development of play areas when "building towns and living spaces." Ultimately, though, there's no proven way to entice the unmotivated to get off the couch, he said.
"I don't know how you can get people to exercise who aren't willing to or don't want to," Roberts said. "In the end, it has to be an individual decision that you're going to make the changes you need."
As the Let's Move! campaign enters its second year, it's not without political detractors. Some have criticized the first lady and the program for what they suggest is an overstepping of government bounds.
On his radio program earlier this year, talk show host Rush Limbaugh said that Obama was "urging, demanding, advocating, requiring what everybody can and can't eat."
But health experts continue to suggest that Let's Move! is on the right track, if perhaps not far-reaching enough.
"The obesity epidemic is caused by a toxic environment," said David Ludwig, who developed the Optimal Weight for Life program at Children's Hospital Boston. To truly combat it, he says, government involvement needs to include providing subsidies for farms that grow nutritious foods, as well as better funding for schools so that food quality and physical education aren't sacrificed.
Wootan adds that marketing that targets children, such as television commercials and kid-themed packaging, also needs to be curtailed.
Hill believes that until more research is done to find creative solutions to the childhood obesity epidemic, the problem may not be going anywhere.
"I think things may get worse," he said, "before they get better."
Type 2 Diabetes Surges in People Younger Than 20
March 21, 2011, The Washington Post
By Susan Brink
Annie Snyder figured she'd be out of the pediatrician's office in 30 minutes, tops. Then she'd head home, tuck the medical permission for YMCA summer camp in her bag and finish packing.
But that exam last summer wasn't like any other she'd had in her 16-year, basically healthy life. Within minutes of learning the results from a urine test, she got two corroborating blood tests and was hustled off to Inova Fairfax Hospital. Lying on a gurney in the emergency room, she heard the word "diabetes" several times and knew from the urgent medical reaction that it was bad. Frightened and crying, she thought: "What have I done to myself?"
Doctors had discovered that Annie had Type 2 diabetes, a disease that is often linked to being overweight. She never made it to summer camp. By the time she came home from the hospital a week later, she knew how to inject herself with insulin and she knew that she'd have diabetes for the rest of her life.
As recently as the mid-1990s, Type 2 diabetes was almost exclusively a disease of adults. But apparently fueled by the childhood obesity epidemic, cases in people younger than 20 have ramped up from virtually zero to tens of thousands in the United States in little more than a decade. The children who have it are breaking new scientific ground: No one has any idea how they will fare over the course of a lifetime.
Annie says she was "most definitely overweight" at the time of her diagnosis, and she has already made major lifestyle changes to control the disease. By exercising and cutting back on carbohydrates, she has lost 12 pounds so far. She has reduced her need for insulin from several injections a day to just one each night, and she's hoping that soon she'll be able to put the needle aside and just use an oral drug, metformin.
Although she is the only person in her household with diabetes, Annie's diagnosis triggered a family response. Her parents got rid of the dining room table and turned that space into an exercise room, complete with a bowl of apples and artfully arranged bottles of water at the door. Everyone exercises, including her 15-year-old brother, Stephen; everyone has given up sodas and snacks, everyone eats smaller portions.
"When I see my dad exercise, I know that I've helped get him motivated," Annie says. "Before, exercise was a chore. I would sit and watch TV and eat snacks. Now, as soon as I come home, I put on my workout clothes."
A disturbing trend
Today, about 3,700 Americans under the age of 20 receive a diagnosis annually of what used to be called "adult-onset" diabetes, according to the Centers for Disease Control and Prevention. That relatively small number makes it a rare disease in children, but it represents a trend with larger ramifications.
"In a little more than 10 years, the numbers went from nothing to something," says Larry Deeb, a pediatric endocrinologist and past president of the medicine and science division of the American Diabetes Association. "And that's something to worry about."
Diabetes can cause a litany of medical woes, including heart disease, kidney failure, limb amputations and blindness. It costs the U.S. health-care system $174 billion a year, according to the National Institutes of Health.
Those statistics are grim enough when patients are in their 60s. When the diagnosis is made decades earlier, new fears are raised: Will these children suffer heart attacks in their 20s, need kidney dialysis in their 30s or go blind before they see their own children graduate from high school?
Because about 80 percent of Type 2 diabetes patients are overweight or obese, it's not surprising that patients such as Annie ask if they've done this to themselves. But there are other risk factors that no one can control: family history, ethnicity (blacks, Hispanics and American Indians have higher rates of diabetes), genetics or a mother who had diabetes during her pregnancy. Instead of wallowing in regret, doctors suggest that young patients and their parents seize the opportunity for a crash course on how to improve their health.
"I used to wear a button that said 'Stamp Out Guilt,' " says Fran Cogen, director of the Child/Adolescent Diabetes Program at Children's National Medical Center. "I try to tell people that no one caused their diabetes. I emphasize that they can make changes now."
Alarm bells are going off among those who study diabetes in children because of what they know about the adult version of the illness. More than 25 million Americans have diabetes (more than 90 percent have Type 2), according to the National Institute of Diabetes and Digestive and Kidney Diseases — but an additional 79 million have a condition called pre-diabetes, in which blood sugar levels are higher than normal but not as high as in diabetes.
Pre-diabetes isn't a disease requiring medical treatment — it's a wake-up call. A large national study showed that adults with pre-diabetes who lost 7 percent of their body weight reduced their risk of diabetes by 58 percent.
Officials are concerned that the number of children already identified as having Type 2 diabetes is just the tip of the iceberg. In a national study of 2,000 eighth-grade students from communities at high risk for diabetes, more than half of the kids were overweight or obese. Only 1 percent had diabetes — but almost a third of them had pre-diabetes, according to Lori Laffel, chief of the Pediatric, Adolescent and Young Adult Section of the Joslin Diabetes Center in Boston and a principal investigator on the study.
It's crucial, she says, to find those children before their condition progresses to diabetes so that it can be reversed by lifestyle changes, without medication.
If there is any good news in childhood diabetes, it is that pediatricians are starting to look for it. "It's in the news, and all over the medical literature," says Susan Conrad, a pediatric endocrinologist at Inova Fairfax Hospital. "Pediatricians are on top of it."
For example, sometimes children whose bodies are beginning to have problems regulating insulin develop a telltale dark, velvety rash around their necks. A decade ago, such a child might have been referred to a dermatologist. In addition, CDC guidelines suggest that a child with a family history of diabetes, or one whose weight is above the 85th percentile for age and sex should be screened, with blood and urine tests, for diabetes.
Family experiences made John Perrone of Winchester, Va., aware of diabetes and its consequences. John's mother, who developed gestational diabetes during all three of her pregnancies, now has Type 2 diabetes. His mother's aunt had diabetes, and by the time she died in her 70s, she was on dialysis, in a wheelchair, legally blind and had suffered two strokes.
John got a diagnosis of Type 2 diabetes four years ago, and he has worked hard ever since to keep the disease under control. He says he's gone from an overweight 11-year-old to a husky but fit 15-year-old. He has progressed from needing insulin injections to keeping his glucose under control with oral medication, combined with healthful eating and a lot of exercise.
He has learned enough to want to teach other kids with the disease. As an Eagle Scout project, he has developed a PowerPoint presentation aimed at youngsters. He has translated medical terms, such as glucose and glucometer, into words they understand, such as sugar and meter. He has also wanted to simplify for kids the basics of weight loss, which is so crucial for diabetes control. "It's all about in and out, what you eat, how much you exercise," he says. "Maybe if kids understand it better, they can do it."
Vilsack: Schools to Receive More Fresh Produce
March 24, 2011, Food Safety News
By Gretchen Goetz
About four million elementary students should receive a free vegetable or fruit snack at school next year, thanks to the expansion of a U.S. Department of Agriculture program, Agriculture Secretary Tom Vilsack announced in March.
Vilsack said USDA plans to put $158 million into its Fresh Fruit and Vegetable Program for the 2011-12 school year; the expanded assistance could help to benefit an estimated 600,000 to 950,000 more students than were served this year.
The Fresh Fruit and Vegetable Program was authorized and funded under the National School Lunch Act and expanded in recent years as a result of the 2008 Farm Bill. It operates in selected low-income elementary schools. Each student receives between $50 and $75 worth of fresh produce over the school year.
The program has been a success, both with kids and the U.S. produce industry.
"This program is very popular. It's a hit with kids, with the parents and with the schools, and it's having an undeniably positive effect not only on the way kids eat at school but also on their eating habits at home," said Dr. Lorelei DiSogra, vice president of Nutrition and Health for the United Fresh Produce Association in a statement.
Kevin Concannon, USDA Under Secretary for Food, Nutrition and Consumer Services, said in a news release, "I am pleasantly surprised when children tell me it was their first time trying a particular fruit or vegetable. Fortunately children are learning fruits and vegetables are healthy choices and tasty alternatives to snacks high in fat, sugar, or salt."
Deconstructing 'The Very Hungry Caterpillar': Excellent Food Choices, Portion Control Needs Work
March 8. 2011, Los Angeles Times
By Melissa Healy
Eric Carle's famous book "The Very Hungry Caterpillar" has become a foot soldier (well, a many-footed soldier) in the war against child obesity.
The storybook character, beloved by parents and children since he emerged from an egg -- pop! -- on a Sunday morning in 1969 is not exactly the exemplar of good eating habits himself. But the American Academy of Pediatrics and a consortium of philanthropic groups has decided that parents can point to the omnivorous larva to convey a few important messages about healthy eating (while their wee ones poke their tiny fingers into the various fruits and food items devoured by the very hungry caterpillar).
Starting in March, more than 17,500 pediatricians' offices are to receive free copies of "The Very Hungry Caterpillar," packaged with growth charts and a reading guide designed to help parents use the story to talk to their young children about healthy eating. The packages are an initiative of the Alliance for a Healthier Generation (the anti-obesity campaign established by the American Heart Association and former President Bill Clinton) and two literacy groups: the Pearson Foundation and We Give Books, a digital initiative of "The Very Hungry Caterpillar's" publisher, Penguin Books.
For those whose children have long since built a cocoon around themselves -- or become beautiful butterflies -- here's a recap of the very hungry caterpillar's story: From the moment he pops out of his egg in the warm sun, he is propelled by his hunger to look for food. Between Monday and Friday, he eats his way through a great deal of fruit. But on Saturday, his hunger really gets the better of him, and he eats through a piece of chocolate cake, an ice cream cone, a pickle, a slice of Swiss cheese, some salami, a lollipop, a piece of cherry pie, one sausage, a cupcake, and a slice of watermelon. (Being a caterpillar and all, he burrows a tunnel through all these foods just big enough for a small finger to poke into.)
Following this excessive intake of saturated fat, sodium and high-fructose corn syrup, he is diagnosed with gastroesophogeal reflux disease (GERD) and begins a regimen of proton pump inhibitors. (Just kidding -- that night, Eric Carle reports, "He had a stomachache!")
This cautionary tale, it turns out, provides some important teaching moments. Children can be induced to notice all the terrific fruits the caterpillar consumes, and to suggest more (which they might come to think of as snacks). Parents can pointedly note the unhappy results of his weekend binge -- the stomachache -- and remind their child that a sensation of fullness is a good signal that it's time to stop eating. Readers might observe that the consumption of "one nice green leaf" on Sunday made the very hungry caterpillar feel "much better." And for the scientifically minded child, there's even a lesson in cumulative effects: despite his Sunday of calorie restriction, the caterpillar enters the next stage of his life bearing the cumulative effects of his excessive consumption: "He was a big, fat caterpillar"--with a significant case of abdominal adipose deposition to show for it.
Author and illustrator Eric Carle says he's thrilled that his creation has metamorphosed into a "spokescharacter" for an anti-obesity campaign. Quoted in an announcement for the campaign, he says, "I hope 'The Very Hungry Caterpillar' will be a happy reminder for children to grow healthy and spread their strong wings, like the butterfly in my book."